Discharge Planning for Patients with Longer Stays Video Transcript
Discharge planning for patients who are housing unstable with longer stays.
Caleb was admitted to the hospital about two weeks ago for psychiatric evaluation and it is clear he will be staying for a while longer. Before being admitted to the hospital, Caleb had been staying in the local shelter for a few months. After speaking with Caleb and calling the shelter where he was staying, there are no immediate ideas of where Caleb may be able to go after discharge, but you learn that he had talked to one of the case managers a few times who helped him complete some housing applications.
What are some next steps you can take in discharge planning with Caleb?
Let’s use the Housing Tool for Hospital Discharge Staff to help you decide.
This is the Housing Tool for Hospital Discharge Staff. Let’s begin.
Is the patient able to care for themselves independently after discharge, and is not a danger to themselves or others? We expect yes.
Was your patient experiencing homelessness immediately prior to admission? Yes.
Was your patient staying in a shelter or living on the street, in a car, in an abandoned building, etc. immediately prior to admission? We know that Caleb was staying in the shelter.
Is the expected length of stay for your patient less than 14 days? No.
You have already completed Action Step 1 by contacting Caleb’s case manager and speaking to Caleb about any family or friends he could potentially stay with after discharge.
Now, you should contact Caleb's health insurance payer to determine ways they can help. The health insurance payer may have clinicians to support discharge planning, assist with completing housing applications, and may have contracts with service providers who specifically support patients experiencing homelessness. If you find that Caleb needs a few more days to secure a housing option upon discharge, health insurance payers may be able to authorize extra administrative days to allow more time for discharge planning.
You should also contact the Department of Mental Health Area Office and see if Caleb is already a DMH consumer. Speak with DMH to determine what housing or respite resources Caleb could access. This is an important step, as it may be an option that has not been explored during his stay in shelter or may lead to housing options that are more readily available.
Next, you should check with Caleb to see if he needs any services like case management or legal support to overcome any barriers that may prevent him from getting housing, such as credit repair or issues related to a criminal background. While talking about one’s past can be challenging for patients, patients should be aware the resource is available to them.
It is also important to take inventory of the wait lists for housing, such as public housing or Section 8, that Caleb has joined. You can talk to Caleb and the case manager at the shelter to get a better idea of where he has already applied, then check where Caleb is on the waitlist and update the address and secondary contacts for communications he may receive from the housing provider. If Caleb is interested, you can help him connect with the local Housing Consumer Education Center (also called HCEC), also linked in the Housing Tool. Make sure to ask the HCEC about options including Rooming Houses and Single Room Occupancy housing.
Keep in mind that there are other resources to meet basic needs or financial obstacles, such as Department of Transitional Assistance benefits like SNAP, that may be helpful as you help Caleb find a housing option.
Last but not least, keep using your housing problem solving skills to help Caleb think of places he may be able to go instead of shelter. Because Caleb is in the hospital and will be staying in one place for a bit longer, he may be willing and interested in reconnecting with his previous support systems over time, like family and friends, which could result in having a place to stay after discharge.
If a housing opportunity does arise, whether that is a DMH respite bed becoming available or finding a family member Caleb can stay with, it is important that you support the coordination it will take to secure that discharge placement. This may include supporting Caleb in completing DMH paperwork, submitting requests for reasonable accommodations like virtual meetings instead of in-person meetings, and coordinating transportation. Keep in mind that some shelters may have teams of people who may be willing to help coordinate or you can identify case management through the DMH Area Office or the local Housing Consumer and Education Centers